Urology

Question 1

Commonest stone type

Answer 1

Calcium oxalate (85%)

hypercalciuria, hypercalcaemia, hyperoxaluria or hypocitraturia

Question 2

Magnesium ammonium phosphate (struvite) stones

Answer 2

Secondary to UTI that breakdown urea into CO2 and ammonia
–> Alkalising urine

Proteus

Question 3

Stone <0.5cm

Answer 3

Should pass conservatively

Question 4

Pelviureteric junction obstruction (idiopathic hydronephrosis)

Answer 4

Moderate hydronephrosis causes ill-defined renal pain or ache that may be exacerbated by drinking large volumes of liquid (Dietls’ Crisis).

May produce a large painless mass in the loin;

Severest form: volume of urine in the hydronephrotic sac may simulate free fluid in the peritoneal cavity

Mx:
Either laparoscopic or open pyeloplasty

Question 5

Retroperitoneal fibrosis

Answer 5

May cause ureteric obstruction and hydronephrosis
-Ureter often difficultto define on imaging

Causes:
Idiopathic
-Mediastinal fibrosis and Dupuytren’s contracture may coexist
-RAISED ESR

Malignant infiltration

Reactive fibrosis
-Radiotherapy, resolving blood clot, or extravasation of sclerosants

Question 6

Innervation for detrusor contraction

Answer 6

S2- S4

Reach the sphincter either by the pelvic plexus or via the pudendal nerves

Question 7

Intra-peritoneal rupture of bladder

Answer 7

Dome rupture –> intra-peritoneal leak

Ileus
Abdominal distension

Trauma with full bladder i.e. alcohol-fuelled fights

Question 8

Management of bladder rupture

Answer 8

Intra-peritoneal
-laparotomy and repair

Extra-peritoneal

• Catheter to relieve any tension
• Conservative management, catheter in for minimum 6-10 days

Question 9

Cancer of the bladder

Answer 9

Most common = transitional cell

Then: squamous cell carcinoma due to chronic inflammation e.g. schistomsomiasis

Rarely: Adenocarcinoma in urachal remnant in dome of bladder or form colorectal metastasis

Question 10

Transitional cell carcinoma

Answer 10

Most common bladder and ureter cancer

Papillary tumours are less aggressive superficial cancers

Ulcerating are much more aggressive.

Question 11

Management of superficial bladder tumours Ta, T1

Answer 11

Transurethral resection of the bladder tumour down to detrusor muscle is desired

If not endoscopic diathermy possible

Intra-vesical mitomycin C useful for multiple lesions

Regular check cystoscopies requried

Question 12

Treatment of carcinoma in situ bladder cancer

Answer 12

Intra-vescial bacille Calmette-Guerin

BCG

Question 13

Management of invasive bladder cancer T2-T3

Answer 13

<70 years –> Radical cystectomy

> 70 years –> Radiotherapy

Cystectomy always necessitates urinary diversion. Where the urethra can be retained, it may be possible to construct a new bladder from colon or small bowel
(orthotopic bladder replacement),

Question 14

Treatment of T4 bladder cancer with fixed organ invasion

Answer 14

Palliative

Resection not possible

Question 15

Mitomycin C

Answer 15

Single intra-vesical dose of mitomycin C post transurethral resection of superficial bladder cancer improves outcomes

Question 16

Management of organised/localised prostate cancer

Answer 16

If patient young / life expectancy >10 years –> treat with curative intent

If Gleeson >/7, indicates high risk of progress so should be treated

If elderly, watchful waiting as most tumours take 10-15 years to be clinically relevant

Question 17

Management of locally advanced prostate cancer

Answer 17

External beam radiotherapy

AND

Hormonal therapy

Surgery is not curative

Question 18

Management of metastatic prostate cancer

Answer 18

Androgen suppression through orchiectomy or through gonadal axis suppression using GnRH

Bone pain can be treated with external beam radiotherapy or strontium

Question 19

Benign prostatic hyperplasia

Answer 19

Hyperplasia of peri-urethral tissues

Forms adenomas in transitional zone

Question 20

Complications of bladder diverticula

Answer 20

Drain poorly causing stasis

Leading to:
Infection
Stones
Tumour

Question 21

Small prostate benign hyperplasia obstruction management

Answer 21

Alpha-blockers

Tamulosin

Question 22

Large prostate benign hyperplasia obstruction management

Answer 22

5alpha-reductase inhibitors

Question 23

Management of acute retention

Answer 23

Catheter

Alfuzosin

TWOC 12 hours later

if fails –> TURP

Question 24

Dribbling incontinence in a child

Answer 24

Ectopic ureter

Question 25

Detrusor-sphincter dyssynergia

Answer 25

UMN lesion

Injury between the sacral segment and the pontine micturition centres

Develops a reflex bladder with impaired or absent
cortical control; that is, the bladder loses the coordination imposed by the pontine micturition centre.

Detrusor becomes overactive and attempted voiding results in detrusor contraction occurring synchronously with that of the external sphincter (detrusor-sphincter dyssynergia)

Result is poor bladder emptying and the development of a thick, trabeculated bladder wall

Question 26

Atonic myogenic bladder

Answer 26

Caused by prolonged outlet obstruction and
is found in the late stages of bladder decompensation.

Most common cause is silent prostatic obstruction, where progressive loss of the desire to void results in overflow incontinence

Question 27

Nerve innervation for micturation

Answer 27

Parasympathetic innervation S2 - S4 to the detrusor

Sympathetic innervation T10 - L2 to bladder neck and proximal urethra

Somatic innervation S2 - S4 to the bladder, pelvic floor and urethra

Question 28

Spinal cord damage and micturation

Answer 28

Below / at the level of T12 -L1
–> Flaccid bladder with overflow

Above T12 -L1 = UMN
–> Overactive bladder with poor coordination, causes poor bladder emptying

Question 29

Seminomas

Answer 29

Arise from Seminiferous tubules

Often low-grade

Sensitive to radiotherapy

Question 30

Teratoma

Answer 30

(non-seminomas)

Arise from primitive germinal cells

Not sensitive to radiotherapy